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quarantined for the remainder of their DEPARTMENT OF HEALTH AND public health or other considerations; or voyage, how should HUMAN SERVICES (3) September 30, 2020. operators encourage passengers to notify A copy of the order is provided below the medical center when they Centers for Disease Control and and a copy of the signed order can be experience COVID–19 symptoms? Prevention found at https://www.cdc.gov/ quarantine/cruise/index.html. 26. How should cruise ship operators No Sail Order and Suspension of decrease or eliminate the risk for Further Embarkation; Second U.S. Department of Health and Human COVID–19 transmission for both Modification and Extension of No Sail Services (HHS) passengers and crew in the following Order and Other Measures Related to Centers for Disease Control and group settings? Operations Prevention (CDC) a. Embarkation and disembarkation? AGENCY: Centers for Disease Control and Order Under Sections 361 & 365 of the b. Safety drills and trainings? Prevention (CDC), Department of Health Public Health Service Act (42 U.S.C. c. Dining? and Human Services (HHS). 264, 268) and 42 Code of Federal ACTION: Notice. Regulations Part 70 (Interstate) and d. Onboard entertainment events? Part 71 (Foreign) e. Shore excursions? SUMMARY: The Centers for Disease Control and Prevention (CDC), a Second Modification and Extension of Summary Questions component of the U.S. Department of No Sail Order and Other Measures Health and Human Services (HHS), Related to Operations 27. What benefits can be expected in announces a second modification and Executive Summary terms of averted deaths and illnesses extension of the No Sail Order and The coronavirus disease 2019 and how does this compare to the Other Measures Related to Operations (COVID–19) pandemic continues to expected financial costs of the above that was issued on April 15, 2020. This spread rapidly around the world with measures? Order applies to cruise ships defined as no treatment or vaccine, with over 12.5 commercial, non-cargo, passenger- 28. Should cruise ship operators be million confirmed cases and over carrying vessels with the capacity to required to designate a responsible 560,000 confirmed deaths worldwide as carry 250 or more individuals company official who will accept legal of July 12, 2020. On July 12, 2020, (passengers and crew) and with an responsibility for failure to implement 230,000 new COVID–19 cases were itinerary anticipating an overnight stay measures to protect public health? reported, the largest single-day tally onboard or a 24-hour stay onboard for worldwide since the epidemic began. It Please note that comments received, either passengers or crew, that are took 3 months to reach the first million including attachments and other operating in international, interstate, or cases of COVID–19, but during one supporting materials, are part of the intrastate waterways, subject to the week in June 2020, 1 million new cases public record and are subject to public jurisdiction of the United States. This disclosure. Comments will be posted on were reported worldwide. Order shall additionally apply to cruise Since HHS/CDC’s original No Sail https://www.regulations.gov. Therefore, ships operating outside of U.S. waters if do not include any information in your Order, signed on March 14, 2020, which the cruise ship operator intends for the restricted the embarkation of comment or supporting materials that ship to return to operating in passengers, CDC has worked to control you consider confidential or international, interstate, or intrastate COVID–19 on cruise ships that inappropriate for public disclosure. If waterways, subject to the jurisdiction of remained at sea, while protecting you include your name, contact the United States during the period that against further introduction and spread information, or other information that this Order is in effect. of COVID–19 into U.S. communities. As identifies you in the body of your DATES: This action was effective July 16, of July 10, 2020, CDC has expended an comments, that information will be on 2020. estimated 38,000 person-hours on the public display. CDC will review all FOR FURTHER INFORMATION CONTACT: cruise ship COVID–19 response since submissions and may choose to redact, Jennifer Buigut, Division of Global March 14, 2020—in addition to the or withhold, submissions containing Migration and Quarantine, Centers for thousands of hours invested by other private or proprietary information such Disease Control and Prevention, 1600 HHS components, other U.S. as Social Security numbers, medical Clifton Road NE, MS V18–2, Atlanta, government agencies, and state and information, inappropriate language, or GA 30329. Phone: 404–498–1600. local authorities. CDC continues to have duplicate/near duplicate examples of a Email: [email protected]. regular conversations by phone and mass-mail campaign. CDC will carefully SUPPLEMENTARY INFORMATION: This email with cruise lines, often daily. consider all comments submitted to this Order renews the No Sail Order and Cumulative CDC data from the period docket. CDC does not accept public Other Measures Related to Operations of March 1 to July 10, 2020 reveal a total comment by email. signed by the CDC Director on March of 2,973 COVID–19 or COVID-like 14, 2020, as further modified and illness cases on cruise ships, in addition Dated: July 16, 2020. extended effective April 15, 2020, to 34 deaths. These data have also Sandra Cashman, subject to the modifications and revealed a total of 99 outbreaks on 123 Executive Secretary, Centers for Disease additional stipulated conditions as set different cruise ships, meaning that 80% Control and Prevention. forth in this Order. of ships within U.S. jurisdiction were [FR Doc. 2020–15812 Filed 7–17–20; 11:15 am] This Order shall remain in effect until affected by COVID–19 during this time BILLING CODE 4163–18–P the earliest of (1) the expiration of the frame. In addition, 9 ships still have Secretary of Health and Human ongoing or resolving COVID–19 Services’ declaration that COVID–19 outbreaks on board. constitutes a public health emergency; The challenges described in this (2) the CDC Director rescinds or document highlight the need for further modifies the order based on specific action prior to cruise ships’ resuming

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passenger operations. CDC supports the • Maintaining the safety of shipping cruise ship operator (e.g., shifting decision by the Cruise Line and harbor conditions. berths, moving to anchor, discharging International Association (CLIA) and its waste, making port, or embarking or Applicability members to voluntarily extend the disembarking passengers or crew) to suspension of operations for passenger This Modification and Extension of bring or cause a cruise ship to be cruise ship travel. However, because not No Sail Order and Other Measures brought into or transit in or between any all cruise ship operators subject to the Related to Operations shall apply only international, interstate, or intrastate No Sail Order are members of CLIA or to the subset of carriers 3 described waterways, or maintaining a ship in have made similar commitments, CDC is below and hereinafter referred to as layup status,8 subject to the jurisdiction extending its No Sail Order to ensure ‘‘cruise ships’’: of the United States. that passenger operations do not resume All commercial, non-cargo,4 passenger- ‘‘Operator’’ means the Master of the prematurely. carrying vessels with the capacity 5 to carry vessel (cruise ship) and any other crew 250 6 or more individuals (passengers and member responsible for cruise ship Previous Orders and Incorporation by crew) and with an itinerary anticipating an operations and navigation, as well as Reference overnight stay onboard or a twenty-four (24) any person or entity (including a This Order renews the No Sail Order hour stay onboard for either passengers or corporate entity) that authorizes or and Other Measures Related to crew that are operating in international, directs the use of a cruise ship (e.g., as interstate, or intrastate waterways, subject to owner, lessee, or otherwise). A cruise Operations signed by the CDC Director 7 on March 14, 2020,1 as further modified the jurisdiction of the United States. ship operator may be either the cruise and extended effective April 15, This Order shall additionally apply to ship captain or the cruise line to which 2020 2—subject to the modifications and cruise ships operating outside of U.S. the cruise ship belongs, or both. The additional stipulated conditions as set waters if the cruise ship operator term ‘‘Operator’’ as used in this Order forth in this Order. intends for the ship to return to further incorporates the terms This Order shall remain in effect until operating in international, interstate, or ‘‘company,’’ ‘‘designated person,’’ and the earliest of (1) the expiration of the intrastate waterways, subject to the ‘‘responsible person’’ as defined in 33 Secretary of Health and Human jurisdiction of the United States during CFR § 96.120. Services’ declaration that COVID–19 the period that this Order is in effect. Events Necessitating the March 14 and constitutes a public health emergency; Definitions April 15, 2020 Orders (2) the CDC Director rescinds or modifies the Order based on specific The following definitions shall apply On January 20, 2020, the Diamond public health or other considerations; or for the purposes of this Order: Princess cruise ship departed (3) September 30, 2020. COVID–19 means the disease caused Yokohama, Japan. On January 25, 2020, The findings and other evidence by the coronavirus SARS-CoV–2. a symptomatic passenger departed the relied upon in issuing the March 14 and ‘‘Operations,’’ ‘‘Operate,’’ and ship in Hong Kong, where he was later April 15, 2020 Orders are incorporated ‘‘Operating’’ means any action by a confirmed to have COVID–19. Upon the herein by reference. Any ambiguity ship’s return to Yokohama, Japanese between the March 14, and April 15, 3 Carrier is defined by 42 CFR 71.1 to mean, ‘‘a authorities quarantined all passengers 2020 Orders, as modified by the current ship, aircraft, train, road vehicle, or other means of and crew on board the ship. Among the transport, including military.’’ Order, shall be resolved in favor of the 3,711 passengers and 4 Given the substantial risk of person-to-person crew, 712 (19.2%) were subsequently current Order. transmission of COVID–19, as opposed to transmission via indirect contact, this Order is confirmed to have COVID–19, 37 Statement of Intent currently limited to passenger, non-cargo vessels. required intensive care, and nine died. This Order shall be interpreted and 5 A ship’s capacity shall be determined based on Following this outbreak, two voyages of implemented in a manner as to achieve the number of persons listed in the U.S. Coast the cruise ship were Guard Certificate of Inspection issued in accordance ultimately associated with 159 the following paramount objectives: with 46 CFR 2.01–5 and that was in effect on the • Preserving human life; date of the signing of this current Order. confirmed COVID–19 cases, including 9 • Preserving the health and safety of 6 Based on substantial epidemiologic evidence eight deaths. cruise ship crew members, port related to congregate settings and mass gatherings, Because of these events, and the personnel, and communities; this Order suspends operation of vessels with the increased risk of transmission on cruise • capacity to carry 250 individuals or more. Evidence ships, on March 14, 2020, the CDC Preventing the further introduction, shows that settings as small as nursing homes or transmission, and spread of COVID–19 movie theaters can proliferate the spread of a Director issued a No Sail Order and into and throughout the United States; communicable disease. As the numbers of Other Measures Related to Operations • Preserving the public health and passengers and crew on board a ship increase, directing cruise ships not voluntarily certain recommended mitigation efforts such as suspending operations to comply with other critical resources of Federal, State, become more difficult to and local governments; implement. In light of the demonstrated rapid certain measures. This followed a March • Preserving hospital, healthcare, and spread of COVID–19 in cruise ship settings, 13, 2020, announcement by CLIA, the emergency response resources within application of this Order to vessels carrying 250 or leading industry trade group, that its more individuals is a prudent and warranted public members would voluntarily suspend the United States; and health measure. Moreover, during the early part of 2020, management of COVID–19 cases in addition cruise ship operations. On March 17, 1 No Sail Order and Suspension of Further to care needs resulting from the seasonal influenza 2020, CDC issued a Level 3 Travel Embarkation. www.federalregister.gov/documents/ epidemic placed an extreme burden on public 2020/03/24/2020-06166/no-sail-order-and- health and healthcare systems and this Order will 8 Layup means reducing cruise ship operations to suspension-of-further-embarkation. Last accessed help avoid further stressing those systems. those levels needed to maintain essential machinery June 24, 2020. 7 This order shall not apply to vessels operated by and equipment so that the ship may be returned to 2 No Sail Order and Suspension of Further a U.S. Federal or State government agency. Nor service. Embarkation; Notice of Modification and Extension shall it apply to vessels being operated solely for 9 Moriarty LF, Plucinski MM, Marston BJ, et al. and Other Measures Related to Operations. purposes of the provision of essential services, such Public Health Responses to COVID–19 Outbreaks www.federalregister.gov/documents/2020/04/15/ as the provision of medical care, emergency on Cruise Ships—Worldwide, February–March 2020-07930/no-sail-order-and-suspension-of- response, activities related to public health and 2020. MMWR Morb Mortal Wkly Rep 2020;69:347– further-embarkation-notice-of-modification-and- welfare, or government services, such as food, 352. https://www.cdc.gov/mmwr/volumes/69/wr/ extension-and-other. Last accessed June 24, 2020. water, and electricity. mm6912e3.htm. Last accessed June 25, 2020.

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Health Notice warning all travelers to Events Since the Issuance of the April also further assisted cruise ship defer cruise travel worldwide based on 15, 2020 Extension operators with humanitarian medical widespread ongoing transmission of evacuations for people in need of Under the April 15, 2020 Extension, COVID–19.10 Despite the announcement lifesaving support. As of July 10, 2020, as a condition of obtaining controlled by CLIA, the application of the March CDC has worked with cruise ship free pratique to continue to engage in 14, 2020 Order, and the Level 3 Travel operators to assist in the disembarkation cruise ship operations in any Health Notice, cruise ships continued to and safe return home of approximately international, interstate, or intrastate be associated with COVID–19 outbreaks. 8,825 crew members, including 314 U.S. waterways subject to the jurisdiction of Between March 14 and April 15, 2020, citizens and residents. the United States, cruise ship operations COVID–19 outbreaks were reported on Under the April 15, 2020 Extension, were limited, and cruise lines were several additional cruise ships. These CDC established an enhanced required to submit plans to prevent, included the ships Costa surveillance process to provide a more mitigate, and respond to the spread of Magica and ; Holland complete picture of COVID–19 activity COVID–19 on board to ensure a safe America Line’s Zaandam; the Celebrity on cruise ships. CDC required weekly work environment and disembarkation Eclipse; the ; and submission of the ‘‘Enhanced Data for crew members. The No Sail Order ’ . Collection (EDC) During COVID–19 (NSO) response plans had to minimize COVID–19 outbreaks on cruise ships Pandemic Form.’’ The EDC form was to the greatest extent possible any required 27 notifications by CDC to used to conduct surveillance for impact on U.S. government operations international, state, and local health COVID–19 among crew who remained or the operations of any State or local departments for over 11,000 cruise ship on board cruise ships based on government, or the U.S. healthcare passengers requiring contact tracing, cumulative reports of acute respiratory system. While working with cruise ship 12 which resulted in countless hours of illness (ARI), influenza-like illness operators to ensure the completeness 13 work for numerous already-burdened (ILI), pneumonia, and other clinical and accuracy of these response plans, public health officials. This number indicators. As of July 10, 2020, EDC CDC allowed crew members to exceeded that of the number of contacts reports have shown a total of 4,590 disembark from cruise ships in U.S. identified from flight investigations polymerase chain reaction (PCR) tests waters and return home if cruise ship since the beginning of the pandemic. performed, 281 (6%) of which were operators attested to complying with Medical evacuation efforts necessitated positive, 18 hospitalizations, 2 instances requirements to disembark crew by these outbreaks required resource of mechanical ventilation, and 9 members in such a manner as to intensive operations that involved medical evacuations for crew on ships minimize the risk to other travelers and multiple small boats to ferry contagious within U.S. jurisdiction since April 15, communities. Among other crew to shore and high levels of 2020. CDC recommended that ships’ requirements, safe disembarkation coordination between Federal, State, surveillance include routine testing for meant not using commercial transport and local public health, maritime, and SARS-CoV–2 infection, including for disembarking crew, screening other governmental authorities. intermittent testing of a random sample disembarking crew members for illness, Response efforts drew valuable of symptomatic and asymptomatic crew ensuring that crew members with resources away from the immense members. known exposure to COVID–19 traveled In addition to reviewing the NSO Federal, State, and local efforts to separately from those with no known response plans, CDC continued to contain and mitigate the spread of exposure, providing face masks or cloth update its Interim Guidance as new COVID–19. State and local public health face coverings to disembarking crew information became available; provided officials further stated that they faced an members or confirming that they had technical expertise to ships with increasing burden supporting cruise their own face coverings, and ongoing outbreaks; created cruise ship- ships attempting to make port with ill instructing disembarking crew members specific websites to inform crew passengers or crew and struggled to to stay home for 14 days and continue members, the public, and partners; and repatriate passengers and crew while to practice social distancing after reviewed hundreds of attestations for also protecting the limited medical reaching their final destination. This safe disembarkation and transfer of crew assets available to their communities. disembarkation process proved members. The intensive care requirements for cumbersome and labor intensive; it is CDC also established a ‘‘COVID–19 infected passengers and crew in need of still ongoing even now with over 14,000 Color Coding System’’ for ships life-saving critical care also greatly crew remaining onboard, due in part to applicable to cruise ship operators with stressed an already overtaxed healthcare limited charter flight availability, cruise an appropriate NSO response plan for system that at the time was facing lines’ cost burdens, and some crew management. Classification of shortages of masks, test kits, beds, and destination countries’ refusing to accept ships under this system requires cruise ventilators needed to respond to returning crew. company officials to sign an COVID–19. acknowledgment of the completeness Accordingly, to protect public health Following the April 15, 2020 and accuracy of their NSO response and safety and prevent the further Extension, CDC published its Interim plans upon completion of CDC review introduction, transmission, and spread Guidance for Mitigation of COVID–19 of the plan. CDC additionally provides of COVID–19 into and throughout the Among Cruise Ship Crew During the a provisional color status for ships United States, the CDC Director issued Period of the No Sail Order to assist belonging to cruise lines that do not yet an Order modifying and extending the cruise ship operators in preventing, detecting, and medically managing previous March 14, 2020 Order, which quarantine/cruise/management/interim-guidance- became effective on April 15, 2020. confirmed and suspected SARS-CoV–2 infections and exposures among crew no-sail-order.html 12 Acute Respiratory Illness (ARI) is defined as 11 10 CDC Travel Health Notice, COVID–19 and members. During this period, CDC the presence of cough, sore throat, or rhinorrhea in Cruise Ship Travel, at: https://wwwnc.cdc.gov/ the absence of fever. travel/notices/warning/coronavirus-cruise-ship 11 CDC, Interim Guidance for Mitigation of 13 Influenza-like Illness (ILI) is defined as fever (originally posted, March 17, 2020). Last accessed COVID–19 Among Cruise Ship Crew During the (100.4 °F [38 °C]) plus either cough or sore throat June 25, 2020. Period of the No Sail Order at: https://www.cdc.gov/ in the absence of another diagnosis.

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have a complete and accurate plan. CDC disembarkations-commercial- disembark asymptomatic crew safely; assesses the status of a ship by travel.html. missing shoreside and onboard testing reviewing surveillance data from the agreements, supplies, and protocols; not Difficulty of Cruise Ship Operators in weekly EDC form. isolating symptomatic crew; failing to Submitting Appropriate Response Plans • ‘‘Green’’ ship status means that a close self-service buffets, salons, gyms, ship has no confirmed cases of COVID– As of April 29, 2020, CDC had and recreational water facilities; lack of 19 or COVID-like illness for 28 14 received NSO response plans from ability to provide the required level of consecutive days among crew members seven cruise ship operators representing medical care; and implementing social onboard. In addition, cruise ship approximately 110 cruise ships or about distancing and other restrictions only operators must sign an attestation that if 95% of cruise ships subject to the April when physically present in U.S. waters. the ship received ship-to-ship transfers, 15, 2020 Extension. These operators CDC has provided feedback to assist the crew members came from a ship included Carnival Corporation,15 Royal cruise lines in determining how best to with no cases of COVID–19 or COVID- Caribbean Cruise Line, Norwegian address these concerns. like illness within the 28 days before the Cruise Lines, Disney Cruise Lines, By July 10, 2020, cruise ship operators transfer occurred and that land-based Virgin Voyages, Windstar Cruises,16 and had reduced the number of cruise ships crew embarking the ship were Bahamas Paradise Cruise Lines. MSC they proposed to operate in U.S. waters immediately quarantined for 14 days. Cruises submitted an NSO response to approximately 49 ships, with some Ships achieving ‘‘Green’’ status may use plan on May 7, 2020, covering three of operators choosing to temporarily commercial travel to disembark crew its ships. withdraw all ships remaining in U.S. members and may lessen onboard In order to manage the public health waters. As of July 10, 2020, one cruise restrictions to allow crew to resume crisis occurring at sea, including ship operator representing only one some daily interactions with fellow analyzing epidemiologic data, reviewing cruise ship operating in U.S. waters had crew members, including social and responding to NSO response plan an NSO response plan meeting all the gatherings, group meetings, and use of submissions, and managing the safe elements described in the April 15, 2020 group settings such as crew bars and disembarkation of crew, CDC created a Extension: Bahamas Paradise Cruise gyms. Maritime Unit (MU) staffed with 30 Line. • ‘‘Yellow’’ ship status means that a subject matter experts. The MU previously designated ‘‘Green’’ ship Examples of Potential Non-Compliance developed an email box staffed 7 days With the Extended No Sail Order reported one or more COVID-like illness a week to handle the volume of cruise- cases onboard and that testing for related inquires received by CDC during The difficulty of cruise ship operators COVID–19 is pending. If crew with the pandemic and established daily in submitting appropriate NSO response COVID-like illness are not tested by PCR communications with cruise lines. For plans was compounded by several or if results are not available within 1 the plan review process, two MU team instances of potential non-compliance week of the case being reported, then members were assigned to review each with the requirements of the April 15, the ship’s status changes to ‘‘Red.’’ plan and communicate with the 2020 Extension. On April 29, 2020, CDC Ships with a ‘‘Yellow’’ status are submitting cruise line. The work- sent a Notice of Potential Non- required to resume all preventive intensive plan review process has Compliance with the No Sail Order to measures, with the exception of involved assessing hundreds of in response to requiring crew members to remain in documents from each cruise line to attempts by a crew member to cabins as much as possible during non- determine if they completely and disembark from the Oosterdam without working hours, and are no longer adequately addressed the elements of an cruise line officials’ attesting that precautions to protect public health had eligible for commercial travel of appropriate plan described in the April been taken. This attempted disembarking crew. 15, 2020 Extension. Most plans needed • disembarkation without appropriate ‘‘Red’’ ship status means that one or two complete reviews and revisions, precautions required CDC, U.S. Coast more cases of laboratory-confirmed with one plan requiring seven rounds of COVID–19 or COVID-like illness have Guard, U.S. Customs and Border revisions. Protection, California Department of occurred onboard within the past 28 The plans as initially submitted by Public Health, Los Angeles County days, that ship-to-ship transfers the cruise lines were incomplete and Health Department, and Los Angeles occurred from a ship that was not did not fully meet all the requirements Police Department to leverage valuable ‘‘Green,’’ that embarking crew were not of the April 15, 2020 Extension. Areas immediately quarantined for 14 days, or resources and work together to enforce of major concern included insufficient that the ship failed to submit one or the NSO. In response, Holland America details for monitoring crew onboard; more weekly EDC forms during the past Line stated that the incident was the unspecified quantities of personal 28 days. Ships with a ‘‘Red’’ status must result of confusion between Oosterdam protective equipment, medical and follow all preventive measures, administrative personnel and local port laboratory supplies, and fever-reducing including requiring crew members to agents. As a corrective measure, Holland medications; incomplete plans to remain in cabins as much as possible America Line spoke to the local agents during non-working hours, until the at the Port of Los Angeles and instructed 15 On May 24 and again on June 3, 2020, Carnival ship’s status changes to ‘‘Green.’’ Corporation communicated to CDC that none of its them not to approve further The status of the cruise ship operator operating companies had any ships in U.S. waters, disembarkations unless specifically NSO response plans and the color- nor did they expect to have any ships returning to instructed by shoreside management. coding status for individual ships are U.S. waters before the end of the NSO period. On May 11, 2020, CDC sent a ‘‘Dear Accordingly, CDC has held its review of the updated weekly at https://www.cdc.gov/ Carnival response plan in abeyance. Colleague’’ letter to cruise ship coronavirus/2019-ncov/travelers/crew- 16 While Windstar Cruises initially submitted an operators. The letter stated that CDC NSO response plan for one of its ships, it later was aware of allegations of cruise ship 14 The 28-day period for COVID–19 is based on withdrew its ships from U.S. waters and stated it non-compliance with the April 15, 2020 the public health standard of 2 incubation periods, had no intention of returning those ships to U.S. Extension through social media and which is commonly used to determine that a waters during the period of the NSO. Accordingly, communicable disease of public health concern is CDC has held its review of the Windstar response other sources. Alleged instances of non- no longer circulating in a location. plan in abeyance. compliance included not adhering to

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social distancing protocols; that CDC had become aware of reports practice because of the role of fomites in unauthorized crew transfers while of alleged non-compliance on several transmission of COVID–19 and advised outside of U.S. waters; not submitting NCLH cruise ships including the it to discontinue this practice on all weekly surveillance data (through the Norwegian Escape, Norwegian Epic, ships across its fleet. Lastly, CDC EDC form); not relocating all crew to Norwegian Joy, Oceania Marina, and requested NCLH explain whether it had single-occupancy cabins with private Seven Seas Navigator. These allegations at any time not relocated all crew to bathrooms; not cancelling all social included not adhering to social single-occupancy cabins with private gatherings; and not closing all crew distancing protocols, not cancelling all bathrooms. bars, gyms, or other group settings. The social gatherings, not relocating all crew On July 9, 2020, CDC received letter requested that cruise ship to single-occupancy cabins with private NCLH’s response to its July 2 letter. operators investigate and report bathrooms, not suspending self-service NCLH stated that it had implemented instances of non-compliance to CDC and buffets, and crew not wearing cloth face new procedures to mandate the wearing explain in writing what corrective coverings when outside individual of face coverings by crew members actions had been taken to ensure future cabins. CDC further requested that when outside of individual cabins. To compliance. Only two cruise ship NCLH address the veracity of these reinforce this mandate, it had instituted operators, Virgin Voyages 17 and Royal allegations and outline what corrective ‘‘mask patrols’’ comprised of security Caribbean Cruise Ltd (RCL), and CLIA 18 steps it would take to prevent team members who were authorized to responded in writing. reoccurrences. order crew members back to their cabins On May 13, 2020, RCL responded to On May 29, 2020, NCLH sent a if seen not properly masked in public the May 11 ‘‘Dear Colleague’’ letter response to CDC’s May 22 letter. It cited areas. NCLH also confirmed that it had stating that it had investigated the the difficulty in achieving and discontinued its previous practice of allegations in the six areas described in mandating social distancing among allowing up to four crewmembers to the letter and believed that it was in full crew members at all times. NCLH had dine together at the same table. It further compliance. On June 9, 2020, CDC sent modified dining venues, seating, and confirmed that it understood CDC’s a letter to RCL stating that on May 20, meal service to facilitate social color-coding system and noted that all 2020, CDC had received attestations for distancing, but allowed a ‘‘maximum of gyms, bars, and lounges fleetwide were 64 ship-to-ship transfers occurring from 4 persons at a table’’ onboard all ships. closed and remained closed since the May 12 to May 20 for 21 ships in both It had also ‘‘designated large open-air inception of the NSO. NCLH had also the Royal Caribbean International and area spaces to be utilized by crew at disseminated CDC materials in written Celebrity Cruises, Inc. brands. While their leisure, limiting the amount of form fleetwide to all crew members, RCL had originally represented that people and encouraging social instead of conducting in person these transfers were for crew who met distancing.’’ NCLH stated that ships meetings or trainings on COVID–19. CDC’s criteria for ‘‘recovered’’ from operating with reduced manning limited NCLH further confirmed that it had COVID–19, RCL in later its ability to operate without self-service discontinued self-service meal communications acknowledged that buffets. Lastly, NCLH stated that it operations and in lieu of such self- transferred crew had not met these believed it had exceeded CDC’s service operations had designated crew criteria. Furthermore, while RCL guidance ‘‘by not just asking but members to assist other crew members officials did submit multiple attestations encouraging our crew to wear face during meal service. Lastly, while it had coverings.’’ NCLH’s response did not initially found housing of all crew for these transfers, the attestations were specifically address what corrective members in single-occupancy cabins to submitted belatedly after the transfers actions it would take to align its be infeasible based on the number of were complete. The submitted practices with CDC’s Interim Guidance crew members on board, it confirmed attestations were also per ship, not per and did not address the issue of not that all remaining crew members who disembarkation, and lacked a required relocating crew to single-occupancy had not repatriated were currently disembarkation date. For these reasons, cabins with private bathrooms. housed in single occupancy cabins with the attestations were inconsistent with On July 2, 2020, CDC sent NCLH an private bathrooms. CDC’s Interim Guidance. On June 15, additional notice requesting that it take On June 10, 2020, CDC sent a Notice 2020, RCL responded stating that these immediate corrective action to align its of Potential Non-Compliance with the incidents were due to a practices with the April 15, 2020 No Sail Order to Disney Cruise Lines misinterpretation of the Interim Extension and CDC’s Interim Guidance. (DCL) relating to inadequate spacing Guidance and that it would adjust its CDC asked NCLH to explain with and mixing of staterooms intended for practices in the future. greater specificity what steps it had ‘‘well’’ and ‘‘sick’’ crew and potential On May 22, 2020, CDC sent a Notice taken to instruct crew across its fleet to failure to discontinue buffet meal of Potential Non-Compliance with the wear cloth face coverings when outside service during an ongoing COVID–19 No Sail Order to Norwegian Cruise Line of individual cabins (e.g., through outbreak. These concerns were based on Holdings Ltd (NCLH). The notice stated posted signage or verbal reminders). records and photographs received by CDC further noted that depending on CDC from the Disney Wonder to 17 On May 13, 2020, Virgin Voyages submitted a table size, allowing a maximum of 4 document compliance with elements report listing non-conformities with the NSO. As a corrective measure, it added its NSO response plan persons at a table did not ensure outlined in the April 15, 2020 in its entirety to its company Safety Management maintaining a minimum distance of 2 Extension. CDC also sent DCL a separate System and further advised its ships that any meters (6 feet) from one another during letter documenting its concerns proposed deviations required advance approval. meal service. Furthermore, to the extent regarding a sustained outbreak of 18 On May 14, 2020, CLIA responded to the letter requesting a meeting with the CDC Director to that NCLH had allowed crew to gather COVID–19 or COVID-like illness among further engage with CDC. Subsequently, on June 11, in any group setting, it was advised to crew onboard the Disney Wonder during the CDC Director hosted a teleconference with CLIA discontinue this practice until ‘‘Green’’ the period of the April 15, 2020 and other members of the cruise line industry status onboard the ship had been Extension. Since April 15, 2020, CDC during which CDC responded to questions submitted by CLIA relating to procedures, achieved. Moreover, CDC advised NCLH had received reports of 181 cases of clarifications, and crew transfers and repatriations that operating a self-service meal confirmed COVID–19 and 19 case of under the NSO. operation was considered a high-risk COVID-like illness associated with this

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ship. Of particular concern was the fact to cruise ships with overnight case of COVID–19 or COVID-like illness that this outbreak had continued over a accommodations carrying more than in the past 28 days). ten-week time frame, including before 100 people operating in Canadian Since the issuance of the April 15, the April 15, 2020 Extension, with the waters until October 31, 2020. 2020 Extension, cruise ships with last date of COVID-like illness reported On March 18, 2020, the Governor- significant outbreaks involving to CDC on May 25, 2020. General of the Commonwealth of passengers and crew, such as the On June 24, 2020, DCL responded that Australia declared a human biosecurity Celebrity Eclipse (92 confirmed COVID– inadequate spacing and mixing of emergency that included a ban on 19 cases, 8 suspect/probable COVID–19- staterooms intended for ‘‘well’’ and international cruise ships entering like illness cases) and the Coral Princess ‘‘sick’’ crew occurred because of the Australian ports.20 On May 15, 2020, the (29 confirmed, 107 suspect/probable, challenges of transferring asymptomatic, Governor-General extended the human and 5 deaths), arrived on U.S. shores as symptomatic, and COVID–19-positive biosecurity emergency period for an other countries around the world closed crew members between rooms and additional three months, from June 17 to their ports to cruise ships.23 These limited availability of vacant staterooms September 17, 2020.21 This enabled the outbreaks not only endangered those with balconies. DCL also denied that an Minister for Health on May 20, 2020, to onboard and at seaports, but also ‘‘active’’ buffet meal service was in extend a prohibition on the arrival at exposed travelers and communities place and affirmed that crew members any Australian port of any international throughout the world as sick and would point out desired meal items and cruise ship that had left a foreign port. exposed passengers from ships like the then have other crew members serve These restrictions include direct arrivals Zandaam 24 (10 confirmed, 233 suspect/ those items to them on a plate. In regard and round-trip cruises. On May 22, probable, 7 deaths), , and to the outbreak onboard the Disney 2020, the restriction on cruise ships traversed international Wonder, DCL asserted that any entering Australian waters was airports, boarded planes, and returned discrepancies in reporting positive test extended for a further three months to their homes. The CDC does not have results to the CDC were due to until September 17, 2020. Under this official case counts for the Costa inadvertent error. As a corrective action, restriction, any cruise ship capable of Luminosa and Ruby Princess, which DCL stated that it had reviewed and carrying more than 100 passengers is docked in foreign seaports; however, the reinforced the proper procedures for prohibited from operating cruises in media have reported that these two reporting of illness to the CDC. In Australia. When this restriction went ships are responsible for a significant describing what factors may have led to into effect on March 27, 2020, there number of cases and deaths.14 These the magnitude and duration of this were 28 international cruise ships in outbreaks have continued in crew outbreak, DCL noted that numerous Australian waters. Under the direction members on ships like the Disney crew members who subsequently tested of the Australian Border Force, these Wonder, on which a COVID–19 positive for COVID–19 were ships and their crew safely departed. outbreak spanned 10 weeks and asymptomatic and that some of these In addition, as of July 10, 2020, included 229 confirmed and 43 COVID- crew members served as essential crew numerous countries have restricted like illness cases among crew. and were not quarantined in their rooms passenger cruise ship travel to some The current scientific evidence until the results of ship-wide testing degree. These include Aruba, Barbados, suggests that cruise ships pose a greater were received. Bermuda, British Virgin Islands, risk of COVID–19 transmission than Cayman Islands, Dominican Republic, other settings. A recent article published Actions Taken by Other Countries in in the Journal of Travel Medicine by Regard to Cruise Ship Travel , Grenada, Honduras, Norway, Panama, Seychelles, and Spain. Rocklo¨v et al. demonstrated that the A number of countries have taken Diamond Princess cruise ship Supplemental Information Relating to aggressive steps to mitigate the risks of experienced an onboard R0 (basic COVID–19 exacerbated by cruise ship COVID–19 Transmission Onboard reproduction rate) for COVID–19 of 14.8 travel. On March 9, 2020, Canada’s Cruise Ships before ship-wide quarantine was Chief Public Health Officer issued a As of July 10, 2020, CDC has recorded enacted.25 This means that each case formal health advisory asking all approximately 99 outbreaks of COVID– onboard the Diamond Princess Canadians to avoid travelling on cruise 19 onboard 123 ships within U.S. transmitted COVID–19 to approximately ships because the ships represent a jurisdiction 22 including 958 confirmed 15 other people. This reproduction rate high-risk environment for viral cases, 2,015 suspect/probable cases and is approximately four times higher than transmission of COVID–19. On March 34 deaths. Of the 49 ships currently the R0 of the original epicenter of the 19, 2020, the Canadian Government operating or planning to operate in U.S. outbreak in Wuhan, China, which was issued Ship Safety Bulletin No. 05/2020: waters during the period of the April 15, 3.7, meaning that each person with Deferral of the Canadian Cruise Ship 2020 Extension, COVID–19 activity COVID–19 in the early days of the Season for Vessels Capable of Carrying onboard continues and there still outbreak in Wuhan transmitted the 500 Persons or More until July 1, 2020.19 remain 10 ‘‘Provisionally Red’’ ships disease to approximately four other These regulations restricted cruise ships (i.e., reporting at least one confirmed people. In late February/early March, capable of carrying 500 or more persons, 149 cases of PCR-confirmed COVID–19 including both passengers and crew 20 COVID–19 Legislative response—Human members from accessing ports managed Biosecurity Emergency Declaration Explainer. 23 The Pandemic at Sea. by port authorities, public ports, public www.aph.gov.au/About_Parliament/Parliamentary_ www.washingtonpost.com/graphics/2020/politics/ _ port facilities, and the St. Lawrence Departments/Parliamentary Library/FlagPost/2020/ cruise-ships-coronavirus/. Last accessed June 18, March/COVID–19_Biosecurity_Emergency_ 2020. Seaway until July 1, 2020. On May 29, Declaration. Last accessed June 24, 2020. 24 The Pariah Ship. www.bloomberg.com/ 2020, these restrictions were extended 21 Cruise Ship Prohibition Extended. features/2020-zaandam-pariah-ship/. Last accessed www.newsroom.abf.gov.au/releases/cruise-ship- June 18, 2020. 19 Deferral of the Canadian Cruise Ship Season for prohibition-extended. Last accessed June 24, 2020. 25 Rocklo¨v J, Sjo¨din H, Wilder-Smith A. COVID– Vessels Capable of Carrying 500 Persons or More 22 The U.S. Coast Guard considers certain ships 19 Outbreak on the Diamond Princess Cruise Ship: until July 1, 2020—SSB No.: 05/2020. www.tc.gc.ca/ operating outside of U.S. waters subject to their Estimating the Epidemic Potential and Effectiveness eng/marinesafety/bulletins-2020-05-eng.htm. Last jurisdiction for emergency response purposes. of Public Health Countermeasures. J. Travel Med. accessed June 24, 2020. These ships are not included in CDC’s calculations. 2020; 18;27(3):taaa030. doi: 10.1093/jtm/taaa030.

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(of 589 tour participants) were found testing of symptomatic and to achieve the confidence of regulators among U.S. residents linked to Egyptian asymptomatic crew, to our knowledge, and passengers.’’ Nile Cruises. This heightened rate of only 20 of 49 ships currently operating Additionally, a variety of cruise lines transmission onboard cruise ships has or planning to operate in U.S. waters have promoted interventions to manage been documented in other academic during the period of the April 15, 2020 COVID–19 onboard ships in both online publications.9 26 Cruise ship conditions Extension have performed testing. and in print marketing materials. These amplified an already highly While regular testing is not a panacea interventions include enhanced transmissible disease. and a negative test result cannot be used stateroom cleaning, installation of new Rocklo¨v et al. surmised that this to rule out infection conclusively,27 the air filters, preboarding health heightened rate of transmission is due to addition of viral testing can help detect screenings, increased social distancing, the high population density onboard on infected crew members earlier and increased availability of hand sanitizer, ships, which are typically more densely isolate them from others. Viral testing and more self-service meal options. It populated than cities or most other should be used along with other would thus be of benefit to have further living situations. While this is one measures to decrease transmission,28 industry-led engagement as to which contributing factor, CDC’s surveillance such as symptom screening, isolation strategies, best practices, and data acquired during the period of the and quarantine, routine social procedures, either singularly or in NSO show that drastically decreasing distancing, and frequent handwashing. combination, would be most effective in population onboard does not extinguish Unfortunately, testing requires a rapid protecting the health of passengers, transmission. Other factors likely turnaround of results to be useful, and crew, and global communities. contributing to onboard transmission this has proven particularly challenging CDC will continue to update its are crew living and working in close for ships, even when in port. Difficulties guidance and recommendations to quarters in a partially enclosed may include lack of point-of-care testing specify basic safety standards and environment where social distancing onboard and inadequate staffing to public health interventions based on the may prove challenging even with a collect, track and transport samples. best scientific evidence available. CDC limited number of people onboard. When rapid testing is more available, will also continue to consult with In addition, the recent investigation regular, repeated testing of those on international maritime public health by Payne et al. of transmission onboard board, as recommended in other high- partners on ways to reduce COVID–19 a U.S. Navy ship demonstrated high density workplace settings, may help to transmission on ships and will continue transmission rates and high rates of detect COVID–19 outbreaks. Absent to monitor the global COVID–19 mild disease and asymptomatic wider availability and implementation situation. infection among crew.25 These mild of testing, undetected outbreaks of Findings and Immediate Action presentations and asymptomatic cases COVID–19 among crew are likely to The difficulty to date of cruise ship make case detection and isolation and reoccur. quarantine practices based on clinical operators to submit and adhere to presentation alone challenging. Thus, Lack of Consensus Among Cruise Ship appropriate NSO response plans during covert spread of infection among crew Operators and Need for Additional a time of limited operations, as well as may keep the virus circulating from one Industry-Led Efforts Regarding Safely ongoing concerns relating to non- voyage to the next. The Navy ship Resuming Passenger Operations compliance with disease prevention investigation also demonstrates the Cruise ship operators have taken protocols and continued outbreaks of importance of avoiding onboard tentative steps to advance their public COVID–19 onboard cruise ships, congregate settings. However, with health response to COVID–19, improve highlight the need for further action limited dining options and work areas safety, and achieve readiness to safely prior to resuming passenger operations. Accordingly, and consistent with 42 on board cruise ships, avoiding resume passenger operations. Under the CFR 70.2, 71.31(b), and 71.32(b), the congregate settings is challenging for co-chairmanship of former Health and Director of CDC (‘‘Director’’) finds that crew. Human Services Secretary Michael O. cruise ship travel exacerbates the global Numerous challenges have arisen in Leavitt, two cruise lines, RCL and spread of COVID–19, that the scope of detecting COVID–19 transmission NCLH, have assembled a team of this pandemic is inherently and onboard ships. Although examples can subject-matter experts from a variety of necessarily a problem that is be given from most cruise lines, the disciplines under the moniker of the international and interstate in nature, experiences of four Royal Caribbean ‘‘Healthy to Sail Alliance.’’ The group ships, the Vision of the Seas, Liberty of and such transmission has not been intends ‘‘over the next few months ... the Seas, Enchantment of the Seas, and controlled sufficiently by the cruise ship to conduct a robust, scientifically Adventure of the Seas, particularly industry or individual State or local grounded exploration on issues of cruise illustrate how an undetected COVID–19 health authorities. As described in the line health and safety’’ (emphasis outbreak may occur. These four ships March 14, 2020 Order, cruise ship travel added). Furthermore, this group states reported no confirmed COVID–19 cases markedly increases the risk and impact that it will ‘‘deliver to the cruise lines or COVID-like illness in crew for 28 of the COVID–19 disease epidemic a set of public health recommendations days or longer. However, when crew within the United States. If unrestricted that will provide participating cruise subsequently disembarked in countries cruise ship passenger operations were lines with a guide or pathway as they that required shoreside testing, permitted to resume, infected and pursue their individual company efforts confirmed cases of COVID–19 were exposed persons disembarking cruise detected in 55 crew members. While ships would place federal partners (e.g., 27 Watson J, Whiting PF, Brush JE. Interpreting a CDC has recommended periodic random covid-19 test result. BMJ 2020; 369: m1808. doi: Customs and Border Protection and the https://doi.org/10.1136/bmj.m1808. U.S. Coast Guard), healthcare workers, 26 Payne DC, Smith-Jeffcoat SE, Nowak G, et al. 28 Testing Strategy for Coronavirus (COVID–19) in port personnel, and communities at SARS-CoV–2 Infections and Serologic Responses High-Density Critical Infrastructure Workplaces substantial unnecessary risk. from a Sample of U.S. Navy Service Members — after a COVID–19 Case Is Identified. www.cdc.gov/ USS Theodore Roosevelt, April 2020. MMWR Morb coronavirus/2019-ncov/community/worker-safety- The Director also finds evidence to Mortal Wkly Rep 2020;69:714–721. DOI: http:// support/hd-testing.html. Last accessed June 18, support a reasonable belief that cruise dx.doi.org/10.15585/mmwr.mm6923e4. 2020. ships are or may be infected or

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contaminated with a quarantinable it is held invalid, shall remain valid and collecting any specimens for COVID–19 communicable disease.29 This in effect. testing. reasonable belief is based on In accordance with 42 U.S.C. 264(e), Measures Related To Protecting Public information from epidemiologic and this Order shall supersede any provision Health and Crew Safety Signed on other data included in this document under State law (including regulations April 9, 2020 and Made Effective on and the information described in the and provisions established by political March 14, 2020 Order and the April 15, subdivisions of States), that conflict April 15, 2020 2020 Extension. As a result, persons on with an exercise of Federal authority, These measures were implemented to, board or seeking to board cruise ships including instructions by U.S. Coast among other things, ensure a safe may likely be or would likely become Guard or HHS/CDC personnel environment for crew members to work infected with or exposed to COVID–19 permitting ships to make port or and disembark by requiring the by virtue of being on board at a time disembark persons under stipulated submission of appropriate NSO when cases of COVID–19 are being conditions, under this Order. response plans by cruise ship operators reported in increasingly significant This Order shall be enforceable as a condition of obtaining controlled numbers globally.30 through the provisions of 18 U.S.C. free pratique 32 to continue to engage in Accordingly, under 42 CFR 70.2, the 3559, 3571; 42 U.S.C. 243, 268, 271; and any cruise ship operations in any Director determines that measures taken 42 CFR 70.18, 71.2. international, interstate, or intrastate by State and local health authorities Therefore, in accordance with waterways subject to the jurisdiction of regarding COVID–19 onboard cruise Sections 361 and 365 of the Public the United States. ships are inadequate to prevent the Health Service Act (42 U.S.C. 264, 268) Accordingly, the terms and conditions further interstate spread of the disease. and 42 CFR 70.2, 71.31(b), 71.32(b), for of the Modification and Extension of No This Order is not a rule within the all cruise ships described above for the Sail Order and Other Measures Related meaning of the Administrative period described below, it is ordered: to Operations, intended to protect Procedure Act (‘‘APA’’), but rather an Measures Related To Protecting Public public health and crew safety, signed on emergency action taken under the Health of Communities Signed on April 9, 2020, and made effective on existing authority of 42 CFR 70.2, March 14, 2020 April 15, 2020, as modified and 71.31(b), and 71.32(b). In the event that extended by this order, shall remain in this Order qualifies as a rule under the These measures were implemented to effect. Consequently, it remains ordered: APA, notice and comment and a delay provide public health authorities, in 1. As a condition of obtaining in effective date are not required concert with the cruise ship industry, controlled free pratique to continue to because there is good cause to dispense the necessary pause in operations to engage in any cruise ship operations in with prior public notice and the develop and implement an appropriate any international, interstate, or opportunity to comment on this and robust plan (1) to prevent and intrastate waterways subject to the Order.31 Considering the public health mitigate the further spread of COVID–19 jurisdiction of the United States, cruise emergency caused by COVID–19 based, in communities, and (2) to prevent the ship operators shall develop, among other things, on its potential for spread of the disease onboard and implement, and operationalize, an spread on board cruise ships, it would ensure the health of cruise ship appropriate, actionable, and robust plan be impracticable and contrary to the passenger and crew. to prevent, mitigate, and respond to the public health, and by extension the Accordingly, the following terms and spread of COVID–19 among crew public interest, to delay the issuance conditions of the No Sail Order and onboard cruise ships. and effective date of this Order. Other Measures Related to Operations 2. As a condition of obtaining Similarly, if this Order qualifies as a signed on March 14, 2020, as modified controlled free pratique to continue to rule per the definition in the APA, the and extended by this order, shall remain engage in any cruise ship operations in Office of Information and Regulatory in effect. Consequently, it remains any international, interstate, or Affairs has determined that it would be ordered: intrastate waterways subject to the 1. Cruise ship operators shall not a major rule, but there would not be a jurisdiction of the United States, the disembark or reembark crew members delay in its effective date as the agency cruise ship operator shall make the plan except as directed by the USCG, in has invoked the good cause provision of described in paragraph 1, above, consultation with HHS/CDC personnel the APA. available to HHS/CDC and USCG and, as appropriate, as coordinated with If any provision in this Order, or the personnel. Federal, State, and local authorities. application of any provision to any 3. An appropriate plan is one that carriers, persons, or circumstances, shall 2. Cruise ship operators shall not embark any new passengers or crew, adequately prevents, mitigates, and be held invalid, the remainder of the responds to the spread of COVID–19 provisions, or the application of such except as approved by USCG, or other Federal authorities as appropriate, in among crew onboard cruise ships and provisions to any carriers, persons, or that, at a minimum, addresses the circumstances other than those to which consultation with HHS/CDC personnel. 3. While in port, the cruise ship following elements: operator shall observe health a. Onboard surveillance of crew with 29 COVID–19 is a communicable disease for acute respiratory illnesses, influenza- which quarantine is authorized under section 361 precautions as directed by HHS/CDC of the Public Health Service Act (42 U.S.C. 264) and personnel. like illnesses, pneumonia, and COVID– 42 CFR 70.1, 71.1, as listed in Executive Order 4. The cruise ship operator shall 19, including reporting to HHS/CDC on 13295, as amended by Executive Orders 13375 and comply with all HHS/CDC, USCG, and a weekly basis on overall case counts, 13674. methods of testing, and number of crew 30 Since the March 14, 2020 Order, the number of other Federal agency instructions to global cases of COVID–19 reported by the World follow CDC recommendations and requiring hospitalization or medical Health Organization (WHO) has risen from 142,534 guidance for any public health actions evacuation; to 12,102,328 as of July 10, 2020, with 551,046 relating to passengers, crew, ship, or any deaths. See Situation Reports, WHO, https:// 32 Under 42 CFR 71.1, controlled free pratique www.who.int/emergencies/diseases/novel- article or thing on board the ship, as means permission for a carrier to enter a U.S. port, coronavirus-2019/situation-reports. needed, including by making ships’ disembark, and begin operation under certain 31 See 5 U.S.C. 553(b)(B), (d)(3). manifests and logs available and stipulated conditions.

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b. Reports on the number of crew k. Detailed logistical planning for operate in any international, interstate, onboard the cruise ship and any evacuating and repatriating both U.S. or intrastate waterways subject to the increase in the numbers of crew with citizens and foreign nationals to their jurisdiction of the United States, cruise COVID–19 made to HHS/CDC and respective communities and home ship operators shall continue to follow USCG on a daily basis for as long as the countries via foreign government or CDC’s Interim Guidance for Mitigation cruise ship is within waters subject to industry-chartered private transport and of COVID–19 Among Cruise Ship Crew the jurisdiction of the United States; flights, including the steps the cruise During the Period of the No Sail Order, c. Onboard monitoring of crew ship operator will take to ensure those including reporting to HHS/CDC through temperature checks and involved in the transport are not through weekly submission of the medical screening, including addressing exposed (i.e., without the use of Enhanced Data Collection (EDC) form, frequency of monitoring and screening; commercial flights to evacuate or as may be updated.33 Additionally, d. Training of all crew on COVID–19 repatriate individuals, whether within cruise ship operators shall report to prevention, mitigation, and response or from the United States); USCG via Advance Notice of Vessel activities; l. The projected logistical and Arrival (ANOA), whenever in U.S. e. Protocols for any COVID–19 testing, resource impact on State and local waters. including details relating to the shore- government and public health 3. As a condition of obtaining or side transport, administration, and authorities and steps taken to minimize retaining controlled free pratique to operationalization of laboratory work if the impact and engage with these operate in any international, interstate, onboard laboratory work is not feasible; authorities; all plans must provide for or intrastate waterways subject to the f. Onboard isolation, quarantine, and industry/cruise line management of jurisdiction of the United States, cruise social distancing protocols to minimize suspected or confirmed cases of COVID– ship operators with appropriate NSO the risk of transmission and spread of 19 without resource burden on Federal, response plans shall continue to follow COVID–19; State, or local governments; the COVID–19 Color Coding System g. Onboard medical staffing, including m. Plan execution in all U.S. requiring preventive measures for crew number and type of staff, and geographical areas—all plans must be onboard based on the ship’s status, as equipment in sufficient quantity to capable of being executed anywhere in determined by HHS/CDC. provide a hospital level of care (e.g., international, interstate, or intrastate 4. As a condition of obtaining or ventilators, facemasks, personal waterways subject to the jurisdiction of retaining controlled free pratique to protective equipment) for the infected the United States; and operate in any international, interstate, so as to minimize the need for n. Cleaning and disinfection protocols or intrastate waterways subject to the hospitalization onshore; for affected cruise ships. jurisdiction of the United States, cruise 4. An appropriate plan shall be h. An outbreak management and ship operators with appropriate NSO designed to minimize, to the greatest response plan to provision and assist an response plans shall conduct viral extent possible, any impact on U.S. affected cruise ship that relies on testing for COVID–19 for crew in such government operations or the operations industry resources, e.g., mobilization of a manner as described in the relevant of any State or local government, or the additional cruise ships or other vessels CDC guidance with reporting of results U.S. healthcare system. on the EDC form. to act as ‘‘hospital’’ ship for the infected, 5. The cruise ship operator shall ‘‘quarantine’’ ship for the exposed, and 5. As a condition of obtaining or further ensure that the plan is consistent retaining controlled free pratique to ‘‘residential’’ ship for those providing with the most current CDC care and treatment, including the ability operate in any international, interstate, recommendations and guidance for any or intrastate waterways subject to the to transport individuals between ships public health actions related to COVID– as needed; jurisdiction of the United States, cruise 19. Where appropriate, a cruise ship ship operators must observe the i. Categorization of affected crew into operator may coordinate the risk categories with clear stepwise requirements of this Order, the previous development, implementation, and Orders, and the most current CDC approaches for care and management of operationalization of a plan with other each category; recommendations and guidance for any cruise ship operators, including an public health actions related to COVID– j. A medical care plan addressing industry trade group. onboard care versus evacuation to on- 19, even when outside of U.S. waters for shore hospitals for critically ill crew, Measures Related to Continued any ships that intend to return to U.S. specifying how availability of beds for Protection of Public Health and Crew waters during the period that this Order critically ill at local hospitals will be Safety remains in effect. determined in advance and how the These measures are intended to This Order is effective upon signature cruise ship operator will ensure continue to protect U.S. communities, and shall remain in effect until the acceptance at local medical facilities to ensure a safe environment for crew to earliest of (1) the expiration of the treat the critically ill in a manner that work and disembark, and defer the Secretary of Health and Human limits the burden on Federal, State, and embarkation of passengers until there is Services’ declaration that COVID–19 local resources and avoids, to the a clear pathway for a safe return to constitutes a public health emergency; greatest extent possible, medivac passenger operations. (2) the CDC Director rescinds or situations. If medical evacuation is Accordingly, it is ordered: modifies the order based on specific necessary arrangements for evacuation 1. Cruise ship operators shall must be made with commercial continue to suspend passenger 33 For cruise ship operators with ships that have not been in U.S. waters during the period of the No resources (e.g., ship tender, chartered operations and not embark passengers, Sail Order or voluntarily withdrew their ships, the standby vessel, chartered airlift) and except as approved by HHS/CDC following conditions must be met prior to a ship arrangements made with a designated personnel and USCG, in consultation returning to U.S. waters: (1) Submission of the EDC medical facility that has agreed to with other federal authorities as form for 28-days preceding expected arrival in U.S. waters, and (2) a complete and accurate NSO accept such evacuees. All medical appropriate. response plan, including a signed Acknowledgment evacuation plans must be coordinated 2. As a condition of obtaining or of No Sail Order Response Plan Completeness and with the U.S. Coast Guard; retaining controlled free pratique to Accuracy.

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public health or other considerations; or for Motor Vehicle Safety Strategic Plan, will provide critical information to CMS (3) September 30, 2020. 2020–2029. NIOSH received comments and the public. from 11 respondents including Authority DATES: Comments must be received by professional organizations and the July 27, 2020. The authority for these orders is public. All comments received were Sections 361 and 365 of the Public carefully reviewed and addressed, ADDRESSES: When commenting, please Health Service Act (42 U.S.C. 264, 268) where appropriate. In general, revisions reference the document identifier or and 42 CFR 70.2, 71.31(b), 71.32(b). in response to comments focused on OMB control number. To be assured Note: Elsewhere in this issue of the clarifying the worker groups and consideration, comments and Federal Register, CDC is publishing a research topics that are a priority in the recommendations must be submitted companion notice that requests strategic plan. NIOSH Responses to within 10 days in any one of the information from the public regarding Public Comments documents can be following ways: cruise ship planning and infrastructure, found in the Supporting Documents 1. Electronically. You may send your safe resumption of passenger operations, section on www.regulations.gov for this comments electronically to http:// and summary questions. docket. www.regulations.gov. Follow the Dated: July 16, 2020. John J. Howard, instructions for ‘‘Comment or Robert K. McGowan, Director, National Institute for Occupational Submission’’ or ‘‘More Search Options’’ Chief of Staff, Centers for Disease Control Safety and Health, Centers for Disease Control to find the information collection and Prevention. and Prevention. document(s) that are accepting [FR Doc. 2020–15810 Filed 7–17–20; 11:15 am] [FR Doc. 2020–15672 Filed 7–20–20; 8:45 am] comments. BILLING CODE 4163–18–P BILLING CODE 4163–18–P 2. By regular mail. You may mail written comments to the following address: CMS, Office of Strategic DEPARTMENT OF HEALTH AND DEPARTMENT OF HEALTH AND Operations and Regulatory Affairs, HUMAN SERVICES HUMAN SERVICES Division of Regulations Development, Centers for Disease Control and Attention: Document Identifier/OMB Centers for Medicare & Medicaid lll Prevention Control Number , Room C4–26– Services 05, 7500 Security Boulevard, Baltimore, [CDC–2019–0107, Docket Number NIOSH– Maryland 21244–1850. 331] [Document Identifier: CMS–P–0015A] To obtain copies of a supporting NIOSH Center for Motor Vehicle Safety Emergency Clearance: Public statement and any related forms for the Strategic Plan, 2020–2029 Information Collection Requirements proposed collection(s) summarized in Submitted to the Office of Management this notice, you may make your request AGENCY: National Institute for and Budget (OMB) using one of following: Occupational Safety and Health 1. Access CMS’ website address at (NIOSH) of the Centers for Disease AGENCY: Centers for Medicare & Medicaid Services, HHS. https://www.cms.gov/Regulations-and- Control and Prevention (CDC), Guidance/Legislation/ ACTION: Notice. Department of Health and Human PaperworkReductionActof1995/PRA- Services (HHS). SUMMARY: The Centers for Medicare and Listing. ACTION: Notice of availability. Medicaid Services (CMS) is requesting FOR FURTHER INFORMATION CONTACT: SUMMARY: NIOSH announces the that a new information collection William Parham at (410) 786–4669. availability of NIOSH Center for Motor request (ICR) related to the Medicare Vehicle Safety Strategic Plan, 2020– Current Beneficiary Survey (MCBS) SUPPLEMENTARY INFORMATION: Under the 2029. (OMB clearance 0938–0568) be PRA, Federal agencies are required to processed under the emergency publish notice in the Federal Register DATES: The final document was clearance process. Due to CMS’ concerning each proposed ICR. published on July 15, 2020 on the CDC Interested persons are invited to send website. determination that this collection of information is needed prior to the comments regarding our burden ADDRESSES: The document may be expiration of time periods established estimates or any other aspect of this ICR obtained at the following link: https:// under its regulations, an emergency including the necessity and utility of the www.cdc.gov/niosh/docs/2020-126/ clearance is requested. Once the proposed ICR for the proper default.html. emergency information collection performance of the agency’s functions, FOR FURTHER INFORMATION CONTACT: Kyla request is approved, CMS plans to seek the accuracy of the estimated burden, Retzer, Western States Division, P.O. public comments during the required ways to enhance the quality, utility, and Box 25226, Denver, Colorado 80225– 60-day and 30-day notice and comment clarity of the information to be collected 0226, (303) 236–5934 (not a toll-free periods associated with obtaining a and the use of automated collection number), [email protected] OR Dr. Rosa standard (non-emergency) OMB techniques or other forms of information Rodriguez-Acosta, Division of Safety approval for extending the information technology to minimize the information Research, 1095 Willowdale Road, MS collection request as part of the MCBS collection burden. 1808, Morgantown, West Virginia (collected under 0938–0568). The Contents 26505–2888, (304) 285–6299 (not a toll- approval of this information collection free number), [email protected]. package is necessary because of the This notice sets out a summary of the SUPPLEMENTARY INFORMATION: On urgent need to obtain timely data to use and burden associated with the December 16, 2019, NIOSH published a assess the impact of the coronavirus following ICR. More detailed request for comment in the Federal pandemic on the Medicare population. information can be found in the Register [84 FR 68458] on the draft Adding a COVID–19 Supplement to the collection’s supporting statement and version of the document NIOSH Center MCBS data collection in October 2020 associated materials (see ADDRESSES).

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